WAG 15-08-06-a: Adjudicated Bills

PM 15-08-06-a.

  1. (FCRC) Only count the part of a bill that is the client's responsibility, towards spenddown. Require written proof of the client's responsibility for medical costs from the provider or from the TPL resource of the medical service.
  2. (FCRC) Consider the adjudication date as the date of billing for any part of the bill which is the client's responsibility.

    Example: The total medical expense (doctor) is $200. The service date was 02/10. The bill is submitted to the client's insurance company. 

    On 04/01 the insurance company pays $125 to the doctor, leaving $75 as the client's responsibility. When determining if the client meets spenddown, consider the bill as incurred on 02/10 and the billing date as 04/01. Allow $75 towards spenddown. 

  3. (FCRC) Enter an adjudicated bill in Revised textIES.
    1. New textEnter the total amount of the service in the "Total Amount Billed" field.
    2. New textEnter the client's responsibility, after adjudication, in the "Client Liability Amount" field.
  4. (FCRC) Enter unadjudicated bills on Revised textForm 360C generated by the system.

Hospital Inpatient and Renal/Hemo Dialysis Charges

For renal/hemo dialysis charges the provider must provide:

  • a written statement of charges showing the amount of the dialysis charges,
  • the amount billed or to be billed to Medicare, and
  • a written estimate of the client's liability for medical costs.

For inpatient hospital charges, accept as proof the hospital's written estimate of the amount that a Medicare and/or non-Medicare TPL resource is expected to pay towards a person's medical care costs.

Hospitals may provide a written estimate of the client's liability for medical costs directly to the FCRC.

The statement must show monthly liability incurred by an enrolled client. When this occurs make a determination if spenddown has been met.